Are You Confident of the Diagnosis?

What you should be alert for in the history

Be alert for predictable bruising associated with psychological stress in the absence of a hematologic, vascular, immunologic, or infectious process.

Characteristic findings on physical examination

Characteristic findings include unexplained painful, ecchymotic lesions, mostly on the extremities and the face. Initial symptoms include burning and pain followed by erythema, edema, pruritus, and eventually ecchymoses. Lesions may be accompanied by systemic symptoms; gastrointestinal, rheumatologic, neurologic. Lesions are often precipitated by emotional stress, and may occur after surgery or trauma. Patients often present with a psychiatric comorbidity.

Who is at Risk for Developing this Disease?

What is the Cause of the Disease?

Etiology

The etiology is unclear. Stress and psychiatric disorders frequently are present; possibly etiologic.

Pathophysiology

Postulated mechanisms include a stress-induced increase in endogenous glucocorticoids, causing altered hemostasis, increased fibrinolysis secondary to increased activity of tissue plasminogen activator, and autoerythrocyte sensitization (autosensitization to phosphoglyceride on the RBC membrane). Malingering, factitious disorders are possible; but one must must first rule out organic etiologies. Rule out relationship abuse.

Systemic Implications and Complications

Affected patients tend to have many associated somatic complaints and psychiatric comorbidities. No clear link established between disorder itself and other pathologic biologic entities.

Treatment Options

No controlled studies exist. Treatment should be directed toward lesion control, pain control, and intervention for an underlying or associated psychiatric disorder. Psychotherapy should be suggested as the most effective intervention.

Consider gabapentin 100mg three times a day, titrating to 300mg three times a day, for pain control.

SSRIs and selective norepinephrine reuptake inhibitors (SNRIs) may help associated obsessive-compulsive disorder (OCD) and depressive symptoms. Caution is warranted since there are scattered case reports of bruising with SSRI’s. There are anecdotal suggestions for use of of beta blockers, on the grounds of their efficacy for migraine headaches and reflex sympathetic dystrophy.

Strongly recommend psychotherapy. Suggest to the patient that psychotherapy can diminish the occurrence of the disease and help them deal with the capricious, painful, and cosmetically visible nature of the disease.

Optimal Therapeutic Approach for this Disease

Once confident in the diagnosis, reassure the patient that the prognosis is good. Explain that most will have remission of symptoms (except possible recurrences during stressful periods). Help the patient understand the potential etiologic role of stress as an aggravating factor. This is the rationale for psychiatric referral. Strongly suggest and help facilitate a psychiatric referral, if possible.

Introduce topical and oral agents along with psychotherapy until lesions and symptoms abate. Observe for signs of more severe psychopathology, underlying organic disease, drug use or abuse, physical or emotional abuse.